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Supplemental Information for Capitated and/or Delegated Providers This information is applicable for VHP’s Commercial Employer Group, Covered California and Individual & Family plans for members whose provider, independent practice association (IPA), medical group, or other organized provider entity is paid on the basis of capitation and performs administrative responsibilities on behalf of VHP pursuant to a delegation agreement.
Does this Supplement Apply to Me? This applies if the provider is a: • Capitated provider; or • Delegated provider. To summarize, this supplement applies if: 1. A VHP member has been assigned to or who has chosen a provider (either an individual participating provider or an entity as defined above) that receives a capitation payment from VHP for that member or for the performance of administrative or clinical functions; and 2. The member is covered under a plan insured by or receiving administrative services from VHP.
Capitated Providers What is a capitated provider? Capitation is a payment arrangement for health care providers, which is generally paid based on a per member, per month (pmpm) or a percent of premium. If the provider has an agreement with VHP based on one of these reimbursement methodologies, the provider is considered a capitated provider. VHP pays capitated providers a set amount for each member assigned per period of time, which is generally a month. VHP pays capitation regardless of whether the member seeks care. In most instances, the capitated provider is associated with a medical group or an IPA. Sometimes, the capitated provider is an individual provider, ancillary provider or hospital. Capitated providers may also be subject to VHP’s protocols, policies and procedures related to delegated activities, including by way of example only, submission of encounter data (see Chapter 14, “Encounter Data”) and other requirements reflected in the provider’s agreement with VHP.
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CH 22: Delegated Entities
2021 / Provider Manual
